Bipolar affective disorder

1. NURSING MANAGEMENT
OF CLIENT WITH MANIA
AJITH.K.K,13
th
batch
Msc Nursing

2. WELCOME

3. Identify the famous person

4. What is mood ?
Mood is a pervasive and sustained
feeling tone that is experienced
internally and that influences a
person's behavior and perception
of the world .
Mood can be normal, elevated, or
depressed

5. What is affect ?
Affect is the external
expression of mood.
Healthy persons experience a
wide range of moods and they
feel in control of their moods
and affects.

7. AGITATION

8. The field of psychiatry has considered
major depression and bipolar disorder
to be two separate disorders,
particularly in the last 20 years.
 Bipolar affective disorder (commonly
known as manic depression) is one of
the most common, severe, and
persistent psychiatric illnesses.

9. Chameleon-like in its presentation, the
symptoms may vary from one patient to
the next, and from one episode to the
next within the same patient. The
variety of presentations make this one
of the most difficult conditions to
diagnose.

10. Primary symptom groups and
classification of disorders
Cognitive function
disturbances
Thought and perception
Emotions
Organic psychiatric
disorders
Schizophrenia and
related psychiatric
disorders
Mood (Affective)
disorders

11. The mood spectrum
Depressive stupor
Depression- severe- moderate- mild
Dysthymia
Cyclothymia
Euthymia
Hypomania
Mania
Manic excitement – manic delirium

13. Bipolar affective disorder spectrum
Bipolar disorder NOS
Cyclothymia
BPAD I
BPAD II

15. History
The Old Testament story of King Saul
describes a manic syndrome, as does the
story of Ajax's suicide in Homer's Iliad. About
400 BC, Hippocrates used the terms mania
and melancholia to describe mental
disturbances. Around 30 AD, the Roman
physician Celsus described melancholia.

16. EMIL KRAEPELIN

17. In 1854, Jules Falret described a condition
called folie circulaire, in which patients
experience alternating moods of depression
and mania. In 1882, the German psychiatrist
Karl Kahlbaum, using the term cyclothymia,
described mania and depression as stages
of the same illness
. In 1899, Emil Kraepelin ,described manic-
depressive psychosis

18. The annual incidence of bipolar illness is less
than 1 percent.
Sex
Bipolar I disorder has an equal prevalence
among men and women. Manic episodes are
more common in men, and depressive
episodes are more common in women.

19. When manic episodes occur in women,
they are more likely than men to
present a mixed picture (e.g., mania
and depression). Women also have a
higher rate of being rapid cyclers,
defined as having four or more manic
episodes in a 1-year period.

20. Age
The age of onset for bipolar I disorder ranges
from childhood (as early as age 5 or 6) to 50
years or even older in rare cases, with a
mean age of 30. The mean age of onset for
major depressive disorder is about 40 years,
with 50 percent of all patients having an
onset between the ages of 20 and 50.

21. Socioeconomic and Cultural
Factors
A higher than average incidence of bipolar I
disorder is found among the upper
socioeconomic groups.

22. Comorbidity
Individuals with major mood disorders
are at an increased risk of having one
or more additional comorbid Axis I
disorders. The most frequent disorders
are alcohol abuse or dependence,
panic disorder, obsessive compulsive
disorder (OCD), and social anxiety
disorder.

23. Etiology
Many studies have reported biological
abnormalities in patients with mood
disorders. Monoamine
neurotransmitters norepinephrine,
dopamine, serotonin, and histamine
were the main focus of theories and
research about the etiology of these
disorders.

24. Second Messengers and
Intracellular Cascades
Second messengers regulate the
function of neuronal membrane ion
channels. Increasing evidence also
indicates that mood-stabilizing
drugs act on G proteins or other
second messengers.

25. Alterations of Hormonal Regulation
Lasting alterations in neuroendocrine
and behavioral responses can result
from severe early stress. Animal
studies indicate that even transient
periods of maternal deprivation can
alter subsequent responses to stress

26. Thyroid Axis Activity
Approximately 5 to 10 percent of
people evaluated for mood disorders
have previously undetected thyroid
dysfunction, as reflected by an elevated
basal thyroid-stimulating hormone
(TSH) level.

27. Growth Hormone
Growth hormone (GH) is secreted from the
anterior pituitary after stimulation by NE and
Dopamine (DA). Secretion is inhibited by
somatostatin, a hypothalamic neuropeptide.
Increased levels have been observed in
mania.

28. Psychosocial Factors
Life Events and Environmental
Stress
A long-standing clinical observation is
that stressful life events more often
precede first, rather than subsequent,
episodes of mood disorders.

29. Famous people who have publicly
stated they have bipolar disorder
Buzz Aldrin, astronaut
Tim Burton, artist, movie director
Francis Ford Coppola, director
Patricia Cornwell, writer
Ray Davies, musician
Robert Downey, Jr., actor

30. Other famous people who are
thought to have had bipolar disorder
William Blake, Napoleon Bonaparte,
Agatha Christie, Winston Churchill, TS
Eliot,, Cary Grant, Victor Hugo, Robert
E Lee, Abraham Lincoln, Samuel
Johnson, Marilyn Monroe

31. ICD-10 Classification
F30 to F39
Mood (affective) disorders

32. DSM-IV-TR Classification

33. CLINICAL MANIFESTATIONS AND
DIAGNOSTIC CRITERIA — The
diagnosis of a specific mood
disorder is based on a patient's
presenting symptoms and history
of prior symptoms.

34. Mania — Diagnostic criteria for mania
from the American Psychiatric
Association are shown in a table and
include the following: A distinct period
of abnormally and persistently
elevated, expansive, or irritable mood,
lasting at least one week

35. During the period of mood disturbance, at
least three or more of the following
symptoms are present:

 - inflated self esteem or grandiosity
 - decreased need for sleep
 - more talkative than usual
 - racing thoughts or flight of ideas
 - distractibility

36. The most common behavioral
symptoms associated with manic
episodes include pressured speech,
hyperverbosity, physical hyperactivity
and agitation, decreased need for
sleep, hypersexuality

37. Less common features include
violence, religiosity, pronounced
regression, and catatonia.
Impaired insight is a frequent
component of the manic state and
may impair compliance with
medications.

38. Manic clients more prone for
alcoholism

39. Hypomania — Hypomania refers to a
briefer duration of manic symptoms (at
least four days), and is often used to
refer to a less severe level of
symptoms.. Psychosis does not occur
with hypomania, but often does with
mania.

40. Clinical course — The course of
bipolar I disorder is marked by
relapses and remissions, often
alternating manic with depressive
episodes. Ninety percent of
individuals who have one manic
episode have another within five
years.

41. DIFFERENTIAL DIAGNOSIS — Many
psychiatric conditions may mimic, and at
times coexist with, bipolar disorder, including:
schizophrenia; schizoaffective disorder;
posttraumatic stress disorder; abuse of
alcohol, cocaine, or amphetamines; and
personality disorders such as narcissistic,
borderline and histrionic personalities.

42. Mental Status Examination

General Description
Manic patients are excited, talkative,
sometimes amusing, and frequently
hyperactive. At times, they are grossly
psychotic and disorganized and require
physical restraints and the intramuscular
injection of sedating drugs.

43. Mood, Affect, and Feelings
Manic patients classically are
euphoric, but they can also be irritable,
especially when mania has been
present for some time. They also have
a low frustration tolerance, which can
lead to feelings of anger and hostility.

44. Speech
Manic patients cannot be interrupted
while they are speaking, and they are
often intrusive nuisances to those
around them. Their speech is often
disturbed.

45. Perceptual Disturbances
Delusions occur in 75 percent of all
manic patients. Mood-congruent manic
delusions are often concerned with
great wealth, extraordinary abilities.

46. Thought
The manic patient's thought content
includes themes of self-confidence and
self-aggrandizement. Manic patients
are often easily distracted, and their
cognitive functioning in the manic state
is characterized by an unrestrained and
accelerated flow of ideas.

47. Treatment
Treatment of patients with mood disorders
should be directed toward several goals.
First, the patient's safety must be
guaranteed. Second, a complete diagnostic
evaluation of the patient is necessary. Third,
a treatment plan that addresses not only the
immediate symptoms but also the patient's
prospective well-being should be initiated.

48. Hospitalization
Clear indications for hospitalization
are the risk of suicide or homicide,
a patient's grossly reduced ability
to get food and shelter, and the
need for diagnostic procedures.

49. Pharmacotherapy
The objective of pharmacologic
treatment is symptom remission, not
just symptom reduction. Patients with
residual symptoms, as opposed to full
remission, are more likely to
experience a relapse or recurrence of
mood episodes and to experience
ongoing impairment of daily
functioning.

51. Treatment of Acute Mania
The treatment of acute mania, or hypomania,
usually is the easiest phases of bipolar
disorders to treat. Agents can be used alone
or in combination to bring the patient down
from a high. Patients with severe mania are
best treated in the hospital where aggressive
dosing is possible and an adequate response
can be achieved within days or weeks

52. Lithium Carbonate
Lithium carbonate is considered the
prototypical mood stabilizer.  Yet,
because the onset of antimanic action
with lithium can be slow, it usually is
supplemented in the early phases of
treatment by atypical antipsychotics,
mood-stabilizing anticonvulsants.

53. Valproate
Valproate (valproic acid [Depakene] or
divalproex sodium [Depakote]) has
surpassed lithium in use for acute mania.
Unlike lithium, Valproate is only indicated for
acute mania, although most experts agree it
also has prophylactic effects. Typical dose
levels of valproic acid are 750 to 2,500 mg
per day

54. Carbamazepine and Oxcarbazepine
Carbamazepine has been used
worldwide for decades as a first-line
treatment for acute mania, but has only
gained approval in the United States in
2004. Typical doses of carbamazepine
to treat acute mania range between
600 and 1,800 mg per day

55. Clonazepam and Lorazepam
The high-potency benzodiazepine
anticonvulsants used in acute mania include
clonazepam (Klonopin) and lorazepam
(Ativan). Both may be effective and are
widely used for adjunctive treatment of acute
manic agitation, insomnia, aggression, and
dysphoria, as well as panic.

56. Atypical and Typical Antipsychotics
All of the atypical antipsychotics
olanzapine, risperidone, quetiapine,
ziprasidone, and aripiprazole have
demonstrated antimanic efficacy and
are FDA approved for this indication

57. Lithium
Despite problems with tolerability,
lithium still remains the gold standard in
the treatment of bipolar affective
disorder against which other treatments
are measured.. Mode of action
Uncertain numerous effects on
biological systems (particularly at high
concentrations).

58. Starting dose
Usually 400to600 mg given at night,
increased weekly depending on serum
monitoring to max. 2 g (usual dose 800 mg-
1.2 g) actual dose depends upon preparation
used

59. Monitoring
Check lithium level 5 days after starting and
5 days after each change of dose. Blood
samples should be taken 12hrs post-dose.
Once a therapeutic serum level (0.6
to1.2mmol/L) has been established
Continue to check lithium level/ every 3
mths, TFTs every 6 to12 mths, CC every 12
mths.

60. Information for the patient
How and when to take their lithium dose.
What to do if a dose is missed.
What the common side-effects are.
What the longer-term problems may be.
The need for regular monitoring of blood
levels, kidney, and thyroid functioning.
What medicines/illnesses may change the
levels of lithium in the blood.

61. Toxicity
The usual upper therapeutic limit for
12-hour post-dose serum lithium level
is 1.2 mmol/l. With levels >1.5 mmol/l
most patients will experience some
symptoms of toxicity; >2.0 mmol/l
definite, often life-threatening, toxic
effects occur.

62. Early signs and symptoms: Marked tremor,
anorexia, nausea/vomiting, diarrhoea
(sometimes bloody), with associated
dehydration and lethargy.
As lithium levels rise Severe neurological
complications restlessness, muscle
fasciculation/myoclonic jerks, choreoathetoid
movements, marked hypertonicity.

63. Management
Education of patients (methods of avoiding
toxicity e.g. maintaining hydration and salt
intake, and being alert to early signs and
symptoms).
Careful adjustment of dosage may be all that
is required.

64. Valproate/valproic acid
Psychiatric indications
Acute mania (up to 56% effective).
Acute depressive episode (in bipolar
affective disorder) in combination with
an antidepressant data limited.
Prophylaxis of bipolar affective disorder
possibly more effective in rapid cycling.

65. Side-effects and toxicity
Dose-related side-effects GI upset
(anorexia, nausea, dyspepsia,
vomiting, diarrhoea), raised LFTs,
tremor, and sedation if persistent, may
require dose reduction, change in
preparation, or treatment of specific
symptoms for tremor;

66. Treatment guidelines for sodium
valproate
Full medical history (particularly liver
disease, haematological problems, and
bleeding disorders)/full physical
examination; check FBC, LFTs,
baseline ECG.

67. Sodium valproate: Start with a low,
divided dose (e.g. 200 mg bd or tds),
increase every few days or every week
by 200 to 400 mg/day according to
response and side-effects, up to a
maximum of 2500mg/day, or until
serum levels are 50 to125 mmol/l).
Usual maintenance dose 1000to1500
mg/day

68. Carbamazepine
Psychiatric indications
Acute mania (less effective than
lithium/equivalent efficacy to antipsychotics)
alone or in combination with lithium.
Acute depressive episode (in bipolar
affective disorder) alone or in combination
with lithium.

69. Side-effects and toxicity
Unpredictable side-effects Antidiuretic effects
leading to hyponatremia (6 to31%), probably
more common in the elderly, sometimes
developing many months after starting
treatment; decrease in total and free
thyroxine levels/increase in free cortisol
levels

70. ECT has been shown to be one of the
best treatment options in acute mania.
Current practice reserves ECT for
clinical situations where
pharmacological treatments may not be
possible, such as pregnancy or severe
cardiac disease, or when the patient's
illness is refractory to drug treatments.

71. NURSING MANAGEMENT
 Assessment
One of the tragedies of bipolar disorder is its
effect on social and occupational functioning.
Cultural views of mental illness influence the
patient’s acceptance of the disorder.

72. Obtain the general history of the client both
from the client and from the other reliable
source.
a.General or demographic information :
Age,sex,health status,residence,date of
admission.
b.Socioeconomic history :It includes clients
education,occupation,economy ,marital
history.

73. Nursing Diagnosis
Risk for violence directed to self or others
related to hyperactivity, agitation, hostile
behavior and low self – esteem
Nursing Goals – The Client
●Demonstrates decreased restlessness,
hyperactivity, and agitation

74. Nursing interventions
 Provide a safe Environment for the client.
Decrease environmental stimuli whenever
possible. Respond to cues of increased
restlessness agitation by removing stimuli
and perhaps isolating the client.
Provide a consistent, structured environment.
Let the client know what is expected of him
or her’.

75. (2)Nursing diagnosis:
 Risk for suicide related to lack of impulse
control, self destructive tendencies, feeling of
worthlessness, hopelessness, guilt, social
isolation.
 Nursing goals – The client:
●Doesn’t harm himself or her self or others

76. Nursing interventions:
Determine the appropriate level of suicide
precautions for the client.
Ask the client if he or she has a plan for
suicide. Attempt to ascertain how detailed
and feasible the plan is.
The client’s room should be centrally located,
preferably near the nurses’ station and within
view of to staff

77. Nursing diagnosis
 Defensive coping evidenced by
denial of problems, repeated like
exaggeration of achievements.
 Nursing Goals – The Client
 ● Demonstrates increased
feelings of self worth

78. Nursing interventions
Decrease environment stimuli.
Provide consistent structure environment.
Give simple direct explanations

79. Nursing diagnosis
Distributed thought processes evidenced by
tangentiality of ideas and speech,
hallucinations, delusions, loose associations.
 Nursing Goals – The Client
● Demonstrates orientation to person,
place, and time

80. Nursing interventions
Reorient the client to person, place, and time
as indicated. Spend time with the client.
Decrease environmental stimuli whenever
possible. Respond to cues of increased
restlessness or agitation by removing stimuli
and perhaps isolating the client
Set and maintain limits on behavior that is
destructive or adversely affects others.

81. Nursing diagnosis
 Self – care Deficit related to inadequate
food and fluid intake, lack of ability to make
judgment regarding health and self care
needs, inattention to personal needs, hyper
activity, and fatigue.
Nursing Goals – The Client
●Participate in self – care activities.

82.  Nursing Interventions
If necessary, assist, the client with personal
hygiene, including mouth care, bathing,
dressing, and laundering clothes.
Encourage the client to meet as many of his
or her own needs as possible.
Monitor the client’s eating patterns and fluid
intake. You may need to record intake and
output can carry with him or her

83. Nursing diagnosis
 Deficient knowledge regarding
illness and importance of compliance
 Nursing Goal – The Client
● Participates in learning about his or
her illness, treatment, and safe use of
medications

84. Nursing interventions
Teach the client and family or significant
others about manic behavior, bipolar
disorder, and other problems as indicated.
Inform the client and family or significant
others chemotherapy: Dosage, the need to
take the medication only as prescribed

85. Nursing Diagnosis

Ineffective coping related to rumination, fear
of intensity of feelings, guilt, anhedonia,
sleep disturbances

86. Nursing Goals – The Client

●Remain free from self – inflicted harm
●Engages in reality – based interaction

87. Nursing interventions

Provide a safe environment for the client
Continually assess the client’s potential for
suicide.
Reorient the client to person, place, and time
as indicated.
When first communicating with the client, use
simple, direct sentences

88. (8) Nursing diagnosis
Impaired social interactions evidenced by low
self esteem, unsatisfactory or inadequate
inter personal relationship, inadequate social
skills.
Nursing Goals – The Client
●Communicates with others

89. Nursing interventions
Initially, interact with the client on a one
– to one basis.
Encourage the client to pursue
personal interests, hobbies, and
recreational activities.

90. (9)Nursing Diagnosis

Chronic low Self – Esteem related to lack of
involvement, feeling of hopelessness, and
worthlessness, or rejection, feeling of
inferiority.

91. Nursing Goals – the Client
●Verbalizes increased feelings of self-worth

92. Nursing interventions
Convey that you care about the client and
that you believe the client is worthwhile
human being.
Encourage the client to express his or her
feelings; convey your acceptance of the
client’s feelings.
Help the client identify positive aspects about
himself or herself.

93. MANAGEMENT OF VIOLENCE:
A person who loses control of his anger
becomes violent. We must develop the
ability to deal with violent behavior in a
way that minimizes the danger.
Prevention of violence is preferable
if it is possible. The intense anxiety
associated with violent feelings is
communicated interpersonally.

94. Accept the patient as he is, without
retaliation or judgement.
Allow the patient to verbalize his
annoyance.
Don’t’ hurt the patient for his
aggressiveness

96. Rehabilitation
Rehabilitation is the process of enabling the
individual to return to his highest possible
level of functioning.
The goal is usually to reach the pre-illness
functional level. This may be achieved by
assisting the patient, to regain their
strengths, re-learning their old skills or
learning new skills,

97. FOLLOW – UP AND HOME CARE AND
REHABILITATION
●Educate the family about the impact of
untreated mood disorders on the individual’s
life and functional ability.
●Tell the client and family to report any
worsening signs of depression or suicidal
thoughts.

98. Educate the client and family about mood
disorders as illnesses that are not their
“fault”.
●Teach clients and families about the “lag
time” between starting antidepressants and
onset of therapeutic effect.

99. Inform the client that several strategies exist
to manage uncomfortable side effects
including reduced dosages, additional
medications, or switching to another
medication.
●Tell clients about the need to continue
medication and discuss with their prescriber
any desire to stop it.

100. Assignment
Write an assignment regarding ICD-10
diagnostic criteria for mania and submit it on
tomorrow before 1p.m .

101. STUDENT REFERENCES

1.Ahuja and Vyas text book of post graduate psychiatry,2
nd

edition,Jaypee brothers, New Delhi,2003.
2.Lalitha .k ,Mental health and Psychiatric nursing ,, 2
nd

edition,ganjana publishers,Banglore,2004.
3.STUART,LARAIA,principles of psychiatric nursing,7
th

edition,Harcourt private limited. New Delhi.
4.Bhatia.m.s,text book of psychiatric nursing,2
nd
,edition,C BS
publications, New Delhi,2005
5 .ICD-10 classification of mental and behavioral
disorders,A.L.T.B.S publications,New Delhi,2003

102. MANIA
is one of the most
challenging yet
rewarding psychiatric
condition to treat.

104. Thank you
AJITH